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In the treatment of women with abnormal uterine bleeding, once a thorough history, physical examination, and indicated imaging studies are performed and all significant structural causes are excluded, medical management is the first-line approach. Determining the acuity of the bleeding, the patient's medical history, assessing risk factors, and establishing a diagnosis will individualize their medical regimen. In acute abnormal uterine bleeding with a normal uterus, parenteral estrogen, a multidose combined oral contraceptive regimen, a multidose progestin-only regimen, and tranexamic acid are all viable options, given the appropriate clinical scenario. Heavy menstrual bleeding can be treated with a levonorgestrel-releasing intrauterine system, combined oral contraceptives, continuous oral progestins, and tranexamic acid with high efficacy. Nonsteroidal antiinflammatory drugs may be utilized with hormonal methods and tranexamic acid to decrease menstrual bleeding. Gonadotropin-releasing hormone agonists are indicated in patients with leiomyoma and abnormal uterine bleeding in preparation for surgical interventions. In women with inherited bleeding disorders all hormonal methods as well as tranexamic acid can be used to treat abnormal uterine bleeding. Women on anticoagulation therapy should consider using progestin-only methods as well as a gonadotropin-releasing hormone agonist to treat their heavy menstrual bleeding. Given these myriad options for medical treatment of abnormal uterine bleeding, many patients may avoid surgical intervention., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To compare the cost and effectiveness of the levonorgestrel-releasing intrauterine system (LNG-IUS) versus combined oral contraception (COC) and progestogens (PROG) in first-line treatment of dysfunctional uterine bleeding (DUB) in Spain., Study Design: A cost-effectiveness and cost-utility analysis of LNG-IUS, COC and PROG was carried out using a Markov model based on clinical data from the literature and expert opinion. The population studied were women with a previous diagnosis of idiopathic heavy menstrual bleeding. The analysis was performed from the National Health System perspective, discounting both costs and future effects at 3%. In addition, a sensitivity analysis (univariate and probabilistic) was conducted., Results: The results show that the greater efficacy of LNG-IUS translates into a gain of 1.92 and 3.89 symptom-free months (SFM) after six months of treatment versus COC and PROG, respectively (which represents an increase of 33% and 60% of symptom-free time). Regarding costs, LNG-IUS produces savings of € 174.2-309.95 and € 230.54-577.61 versus COC and PROG, respectively, after 6 months-5 years. Apart from cost savings and gains in SFM, quality-adjusted life months (QALM) are also favourable to LNG-IUS in all scenarios, with a range of gains between 1 and 2 QALM compared to COC and PROG., Conclusions: The results indicate that first-line use of the LNG-IUS is the dominant therapeutic option (less costly and more effective) in comparison with first-line use of COC or PROG for the treatment of DUB in Spain. LNG-IUS as first line is also the option that provides greatest health-related quality of life to patients., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Background: The vaginal route is more effective than the other drug delivery routes for some specific indications., Aim: To compare the efficacy of a vaginal progesterone preparation with that of oral dydrogesterone., Methods: A total of 69 women with irregular dysfunctional uterine bleeding were randomly assigned into one of two groups: oral dydrogesterone group (n = 35) and vaginal progesterone group (n = 34). At the end of a three-month treatment period, the women were re-evaluated. The endometrial histology findings and menstrual cycle characteristics were used as primary outcome measures. Pearson chi-square and Fisher's exact test were used for data analysis., Results: Findings from 54 eligible women were evaluated. There was no statistically significant difference in both menstrual recordings and endometrial histology results between the groups., Conclusions: Vaginal micronised progesterone could be an alternative to oral preparations in the treatment of dysfunctional uterine bleeding. This needs to be further evaluated in adequately controlled randomised trials against other effective treatments.

Progesterone-receptor modulators (PRMs) are progesterone-receptor ligands that can exert agonistic, antagonistic or mixed agonist-antagonist effects depending on the cellular context. The mechanisms of action of these compounds are still incompletely understood. PRMs already have several applications in women's health such as emergency contraception, pregnancy termination, management of early fetal demise and cervical maturation. The main indications that will be developed in the future include dysfunctional bleeding and preoperative treatment of uterine myomas. Other future indications may include estrogen-free contraception, treatment of endometriosis and prevention and treatment of breast cancer. However, the available data from mid- to long-term continuous administration studies has raised the issue of endometrial safety. For this reason, long-term applications of PRMs are currently postponed, although windows of treatment with a short course of progestin therapy, or even by a short interruption of treatment, could improve endometrial aspects if needed.

Objective: To assess the effect of a new progestin progestogen only pill (desogestrel) versus an oral contraceptive in the treatment of recurrent endometriosis., Study Design: A randomized prospective clinical study. A group of women with endometriosis (n=40) who showed recurrent dysmenorrhea and/or pelvic pain after conservative surgery, and did not desire a pregnancy. Continuous treatment for 6 months with desogestrel (75 microg/d) (n=20) versus a combined oral contraceptive (ethinyl estradiol 20 microg plus desogestrel 150 microg) (n=20) was performed., Results: A significant improvement of both pelvic pain and dysmenorrhea was observed following each type of treatment (P<0.001). The use of desogestrel progestogen only pill was associated with a breakthrough bleeding in 20% patients, while a significant body weight increase was observed in 15% after oral contraceptive., Conclusions: Both desogestrel and an oral estro-progestinic were effective, safe and low cost therapy of pain symptoms after endoscopic surgery for endometriosis, the former showing an impact on breakthrough bleeding, the later an incidence on body weight increase.

Postmenopausal women using continuous combined estrogen/progestin therapy (ccEPT) are likely to have irregular bleeding or spotting. The use of estrogen with 12-14 days of a progestin is called cyclic (scEPT). This method results in regular endometrial bleeding at a scheduled time. The mechanism(s) involved in this regimen that result in bleeding could be similar to a spontaneous menstrual bleeding episode in a menachal woman, but there are no data in this regard. This aspect of regular scheduled bleeding in postmenopausal women will not be addressed in this article due to the paucity of information. The effect of cyclic progestogen with continuous estrogen on the endometrium could result in similar local mechanisms for endometrial bleeding as seen wth ccEPT. The mechanism(s) involved in endometrial bleeding is unknown. Several reports have highlighted a number of potential pathophysiologic mechanisms. Most of the investigation into the mechanisms involved in endometrial bleeding has been in women using progestin only contraceptive methods not ccEPT. The use of ccEPT could be construed as similar but not identical to that of a continuous progestin only contraceptive since the progestin in ccEPT is delivered daily. The potential mechanism(s) involved in endometrial bleeding includes the following: changes in the ratio of vascular endothelial growth factor to Thrombospondin-1 (pro- versus anti-angiogenic factors); alterations in metalloproteinases and tissue inhibitor of metalloproteinases (TIMP); changes in tissue factor a known haemostasis mediator in the endometrium; and increased endometrial leukocytes with a particular emphasis on uterine natural killer (uNK) cells. Each of these potential causes has been the subject of both in vivo and in vitro investigations. There is no clear linkage between any of these hypotheses and the onset or cessation of uterine bleeding in ccEPT users. No good therapeutic option to control the bleeding or spotting exists at this time. Evaluation and monitoring of the patient regarding endometrial safety is of paramount importance.

The authors compared the therapeutic effectiveness of these different pharmacological methods of preventing dysfunctional menometrorrhagia in adolescents, which were: 1) chorionic gonadotropin, 2) cyclofenil, 3) ovariostatics. Therapy was given during 2 menstrual cycles, and effects were evaluated both during the treatment and for the succeeding 2 cycles. Parameters followed were: a) clinical recovery, b) persistence of spotting, c) effectiveness in inducing ovulation. The results were equally good both in treatment with ovariostatics and ovulation inducers. The latter proved however, more effective during follow-up. Side-effects were very rare, so much so that, in no case was it necessary to suspend treatment.